Claim Adjustment Reason Codes - Palmetto GBA

Medicare Specific Remark CodesLast updated: November 05, 2009Disclaimer:This Medicare Specific Remark Codes PDF document will be updated as needed.For the most current Medicare Specific Remark Codes, please visitwww.wpc-edi.com/codes.Once your claim has been processed, Palmetto GBA will send you a remittance noticethat will provide you with details on your finalized claim. The remittance advice noticecontains message codes which explain how a claim was processed. There are threedifferent sets of codes that are used on the remittance advice notice: Reason Codes,Group Codes and Medicare Specific Remark Codes and Messages.Medicare Specific Remark Codes are used to convey information about remittanceprocessing or to provide a supplemental explanation for an adjustment alreadydescribed by a Claim Adjustment Reason Code. Each Remittance Advice Remark Codeidentifies a specific message as shown in the Remittance Advice Remark Code List.More about Remark Codes on our Web siteTip: Get on the fast track to understanding Medicare Remittance Notices by taking theCMS Web-based training module, 'Understanding the Remittance Advice forProfessional Providers.'ReasonCodesM1M2M3M4DescriptionX-ray not taken within the past 12 months or near enough to the start oftreatment.Start: 01/01/1997Not paid separately when the patient is an inpatient.Start: 01/01/1997Equipment is the same or similar to equipment already being used.Start: 01/01/1997Alert: This is the last monthly installment payment for this durablemedical equipment.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)1

ReasonCodesM13M14M15M16M17M18M19DescriptionOnly one initial visit is covered per specialty per medical group.Start: 01/01/1997 | Last Modified: 06/30/2007Notes: (Modified 6/30/03)No separate payment for an injection administered during an office visit,and no payment for a full office visit if the patient only received aninjection.Start: 01/01/1997Separately billed services/tests have been bundled as they areconsidered components of the same procedure. Separate payment isnot allowed.Start: 01/01/1997Alert: Please see our web site, mailings, or bulletins for more detailsconcerning this policy/procedure/decision.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07)Alert: Payment approved as you did not know, and could not reasonablyhave been expected to know, that this would not normally have beencovered for this patient. In the future, you will be liable for charges forthe same service(s) under the same or similar conditions.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Certain services may be approved for home use. Neither a hospital nor aSkilled Nursing Facility (SNF) is considered to be a patient's home.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing oxygen certification/re-certification.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N2343

ReasonCodesM20M21M22M23M24M25DescriptionMissing/incomplete/invalid HCPCS.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid place of residence for this service/itemprovided in a home.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of miles traveled.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing invoice.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)Missing/incomplete/invalid number of doses per vial.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)The information furnished does not substantiate the need for this levelof service. If you believe the service should have been fully covered asbilled, or if you did not know and could not reasonably have beenexpected to know that we would not pay for this level of service, or ifyou notified the patient in writing in advance that we would not pay forthis level of service and he/she agreed in writing to pay, ask us toreview your claim within 120 days of the date of this notice. If you do notrequest a appeal, we will, upon application from the patient, reimbursehim/her for the amount you have collected from him/her in excess ofany deductible and coinsurance amounts. We will recover thereimbursement from you as an overpayment.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07)4

ReasonCodesM26DescriptionThe information furnished does not substantiate the need for this levelof service. If you have collected any amount from the patient for thislevel of service /any amount that exceeds the limiting charge for the lessextensive service, the law requires you to refund that amount to thepatient within 30 days of receiving this notice.M27M28The requirements for refund are in 1824(I) of the Social Security Act and42CFR411.408. The section specifies that physicians who knowinglyand willfully fail to make appropriate refunds may be subject to civilmonetary penalties and/or exclusion from the program. If you have anyquestions about this notice, please contact this office.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)Alert: The patient has been relieved of liability of payment of these itemsand services under the limitation of liability provision of the law. Theprovider is ultimately liable for the patient's waived charges, includingany charges for coinsurance, since the items or services were notreasonable and necessary or constituted custodial care, and you knewor could reasonably have been expected to know, that they were notcovered. You may appeal this determination. You may ask for an appealregarding both the coverage determination and the issue of whether youexercised due care. The appeal request must be filed within 120 days ofthe date you receive this notice. You must make the request throughthis office.Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)This does not qualify for payment under Part B when Part A coverage isexhausted or not otherwise available.Start: 01/01/19975

ReasonDescriptionCodesM29 Missing operative note/report.Start: 01/01/1997 | Last Modified: 07/01/2008Notes: (Modified 2/28/03, 7/1/2008) Related to N233M30 Missing pathology report.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 2/28/03) Related to N236M31 Missing radiology report.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 2/28/03) Related to N240M32 Alert: This is a conditional payment made pending a decision on thisservice by the patient's primary payer. This payment may be subject torefund upon your receipt of any additional payment for this service fromanother payer. You must contact this office immediately upon receipt ofan additional payment for this service.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)M36 This is the 11th rental month. We cannot pay for this until you indicatethat the patient has been given the option of changing the rental to apurchase.Start: 01/01/1997M37 Service not covered when the patient is under age 35.Start: 01/01/1997M38 The patient is liable for the charges for this service as you informed thepatient in writing before the service was furnished that we would notpay for it, and the patient agreed to pay.Start: 01/01/19976

ReasonCodesM39M40M41M42M44M45M46M47M49DescriptionThe patient is not liable for payment for this service as the advancenotice of non-coverage you provided the patient did not comply withprogram requirements.Start: 01/01/1997 | Last Modified: 11/01/2009Notes: (Modified 2/1/04, 4/1/07, 11/1/09)Claim must be assigned and must be filed by the practitioner'semployer.Start: 01/01/1997We do not pay for this as the patient has no legal obligation to pay forthis.Start: 01/01/1997The medical necessity form must be personally signed by the attendingphysician.Start: 01/01/1997Missing/incomplete/invalid condition code.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid occurrence code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N299Missing/incomplete/invalid occurrence span code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N300Missing/incomplete/invalid internal or document control number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid value code(s) or amount(s).Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)7

ReasonCodesM50M51M52M53M54M55M56M59M60DescriptionMissing/incomplete/invalid revenue code(s).Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid procedure code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N301Missing/incomplete/invalid "from" date(s) of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid days or units of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid total charges.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)We do not pay for self-administered anti-emetic drugs that are notadministered with a covered oral anti-cancer drug.Start: 01/01/1997Missing/incomplete/invalid payer identifier.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid "to" date(s) of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing Certificate of Medical Necessity.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 6/30/03) Related to N2278

ReasonCodesM61M62M64M65M66M67M69DescriptionWe cannot pay for this as the approval period for the FDA clinical trialhas expired.Start: 01/01/1997Missing/incomplete/invalid treatment authorization code.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid other diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)One interpreting physician charge can be submitted per claim when apurchased diagnostic test is indicated. Please submit a separate claimfor each interpreting physician.Start: 01/01/1997Our records indicate that you billed diagnostic tests subject to pricelimitations and the procedure code submitted includes a professionalcomponent. Only the technical component is subject to pricelimitations. Please submit the technical and professional components ofthis service as separate line items.Start: 01/01/1997Missing/incomplete/invalid other procedure code(s).Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N302Paid at the regular rate as you did not submit documentation to justifythe modified procedure code.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)9

ReasonCodesM70M71M73M74M75M76M77M79DescriptionAlert: The NDC code submitted for this service was translated to aHCPCS code for processing, but please continue to submit the NDC onfuture claims for this item.Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 4/1/2007, 8/1/07)Total payment reduced due to overlap of tests billed.Start: 01/01/1997The HPSA/Physician Scarcity bonus can only be paid on theprofessional component of this service. Rebill as separate professionaland technical components.Start: 01/01/1997 | Last Modified: 08/01/2004Notes: (Modified 8/1/04)This service does not qualify for a HPSA/Physician Scarcity bonuspayment.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Multiple automated multichannel tests performed on the same daycombined for payment.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)Missing/incomplete/invalid diagnosis or condition.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid place of service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid charge.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)10

ReasonDescriptionCodesM80 Not covered when performed during the same session/date as apreviously processed service for the patient.Start: 01/01/1997 | Last Modified: 10/31/2002Notes: (Modified 10/31/02)M81 You are required to code to the highest level of specificity.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)M82 Service is not covered when patient is under age 50.Start: 01/01/1997M83 Service is not covered unless the patient is classified as at high risk.Start: 01/01/1997M84 Medical code sets used must be the codes in effect at the time ofserviceStart: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)M85 Subjected to review of physician evaluation and management services.Start: 01/01/1997M86 Service denied because payment already made for same/similarprocedure within set time frame.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)M87 Claim/service(s) subjected to CFO-CAP prepayment review.Start: 01/01/1997M89 Not covered more than once under age 40.Start: 01/01/1997M90 Not covered more than once in a 12 month period.Start: 01/01/199711

ReasonCodesM91M93M94M95M96M97M99M100DescriptionLab procedures with different CLIA certification numbers must be billedon separate claims.Start: 01/01/1997Information supplied supports a break in therapy. A new capped rentalperiod began with delivery of this equipment.Start: 01/01/1997Information supplied does not support a break in therapy. A new cappedrental period will not begin.Start: 01/01/1997Services subjected to Home Health Initiative medical review/cost reportaudit.Start: 01/01/1997The technical component of a service furnished to an inpatient may onlybe billed by that inpatient facility. You must contact the inpatient facilityfor technical component reimbursement. If not already billed, youshould bill us for the professional component only.Start: 01/01/1997Not paid to practitioner when provided to patient in this place of service.Payment included in the reimbursement issued the facility.Start: 01/01/1997Missing/incomplete/invalid Universal Product Number/Serial Number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)We do not pay for an oral anti-emetic drug that is not administered foruse immediately before, at, or within 48 hours of administration of acovered chemotherapy drug.Start: 01/01/199712

ReasonCodesM102M103M104M105M107M109M111DescriptionService not performed on equipment approved by the FDA for thispurpose.Start: 01/01/1997Information supplied supports a break in therapy. However, the medicalinformation we have for this patient does not support the need for thisitem as billed. We have approved payment for this item at a reducedlevel, and a new capped rental period will begin with the delivery of thisequipment.Start: 01/01/1997Information supplied supports a break in therapy. A new capped rentalperiod will begin with delivery of the equipment. This is the maximumapproved under the fee schedule for this item or service.Start: 01/01/1997Information supplied does not support a break in therapy. The medicalinformation we have for this patient does not support the need for thisitem as billed. We have approved payment for this item at a reducedlevel, and a new capped rental period will not begin.Start: 01/01/1997Payment reduced as 90-day rolling average hematocrit for ESRD patientexceeded 36.5%.Start: 01/01/1997We have provided you with a bundled payment for a teleconsultation.You must send 25 percent of the teleconsultation payment to thereferring practitioner.Start: 01/01/1997We do not pay for chiropractic manipulative treatment when the patientrefuses to have an x-ray taken.Start: 01/01/199713

ReasonCodesM112M113M114M115M116M117DescriptionReimbursement for this item is based on the single payment amountrequired under the DMEPOS Competitive Bidding Program for the areawhere the patient resides.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)Our records indicate that this patient began using this item/service priorto the current contract period for the DMEPOS Competitive BiddingProgram.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)This service was processed in accordance with rules and guidelinesunder the DMEPOS Competitive Bidding Program or a DemonstrationProject. For more information regarding these projects, contact yourlocal contractor.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 8/1/06, 11/5/07)This item is denied when provided to this patient by a non-contract ornon-demonstration supplier.Start: 01/01/1997 | Last Modified: 11/05/2007Notes: (Modified 11/5/2007)Paid under the Competitive Bidding Demonstration project. Project isending, and future services may not be paid under this project.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)Not covered unless submitted via electronic claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)14

ReasonCodesM118M119M121M122M123M124M125M126DescriptionLetter to follow containing further information.Start: 01/01/1997 | Last Modified: 11/01/2009Notes: (Modified 4/1/07, 11/1/09)Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code(NDC).Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 2/28/03, 4/1/04)We pay for this service only when performed with a coveredcryosurgical ablation.Start: 01/01/1997Missing/incomplete/invalid level of subluxation.Start: 01/01/1997 | Last Modified: 02/28/2006Notes: (Modified 2/28/03)Missing/incomplete/invalid name, strength, or dosage of the drugfurnished.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing indication of whether the patient owns the equipment thatrequires the part or supply.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N230Missing/incomplete/invalid information on the period of time for whichthe service/supply/equipment will be needed.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid individual lab codes included in the test.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)15

ReasonCodesM127M129M130M131M132M133M134M135DescriptionMissing patient medical record for this service.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N237Missing/incomplete/invalid indicator of x-ray availability for review.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 2/28/03, 6/30/03)Missing invoice or statement certifying the actual cost of the lens, lessdiscounts, and/or the type of intraocular lens used.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N231Missing physician financial relationship form.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N239Missing pacemaker registration form.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N235Claim did not identify who performed the purchased diagnostic test orthe amount you were charged for the test.Start: 01/01/1997Performed by a facility/supplier in which the provider has a financialinterest.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing/incomplete/invalid plan of treatment.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)16

ReasonCodesM136M137M138M139M141M142M143M144DescriptionMissing/incomplete/invalid indication that the service was supervised orevaluated by a physician.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Part B coinsurance under a demonstration project.Start: 01/01/1997Patient identified as a demonstration participant but the patient was notenrolled in the demonstration at the time services were rendered.Coverage is limited to demonstration participants.Start: 01/01/1997Denied services exceed the coverage limit for the demonstration.Start: 01/01/1997Missing physician certified plan of care.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N238Missing American Diabetes Association Certificate of Recognition.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N226The provider must update license information with the payer.Start: 01/01/1997 | Last Modified: 12/01/2006Notes: (Modified 12/1/06)Pre-/post-operative care payment is included in the allowance for thesurgery/procedure.Start: 01/01/199717

ReasonCodesMA01MA02MA04MA07MA08MA09DescriptionAlert: If you do not agree with what we approved for these services, youmay appeal our decision. To make sure that we are fair to you, werequire another individual that did not process your initial claim toconduct the appeal. However, in order to be eligible for an appeal, youmust write to us within 120 days of the date you received this notice,unless you have a good reason for being late.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 4/1/07)Alert: If you do not agree with this determination, you have the right toappeal. You must file a written request for an appeal within 180 days ofthe date you receive this notice.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 12/29/05, 8/1/06, 4/1/07)Secondary payment cannot be considered without the identity of orpayment information from the primary payer. The information was eithernot reported or was illegible.Start: 01/01/1997Alert: The claim information has also been forwarded to Medicaid forreview.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Claim information was not forwarded because the supplementalcoverage is not with a Medigap plan, or you do not participate inMedicare.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Claim submitted as unassigned but processed as assigned. You agreedto accept assignment for all claims.Start: 01/01/199718

ReasonCodesMA10MA12MA13MA14MA15MA16DescriptionAlert: The patient's payment was in excess of the amount owed. Youmust refund the overpayment to the patient.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)You have not established that you have the right under the law to bill forservices furnished by the person(s) that furnished this (these)service(s).Start: 01/01/1997Alert: You may be subject to penalties if you bill the patient for amountsnot reported with the PR (patient responsibility) group code.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: The patient is a member of an employer-sponsored prepaid healthplan. Services from outside that health plan are not covered. However,as you were not previously notified of this, we are paying this time. Inthe future, we will not pay you for non-plan services.Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 4/1/07, 8/1/07)Alert: Your claim has been separated to expedite handling. You willreceive a separate notice for the other services reported.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The patient is covered by the Black Lung Program. Send this claim tothe Department of Labor, Federal Black Lung Program, P.O. Box 828,Lanham-Seabrook MD 20703.Start: 01/01/199719

ReasonCodesMA17MA18MA19MA20MA21MA22MA23DescriptionWe are the primary payer and have paid at the primary rate. You mustcontact the patient's other insurer to refund any excess it may have paiddue to its erroneous primary payment.Start: 01/01/1997Alert: The claim information is also being forwarded to the patient'ssupplemental insurer. Send any questions regarding supplementalbenefits to them.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Information was not sent to the Medigap insurer due toincorrect/invalid information you submitted concerning that insurer.Please verify your information and submit your secondary claim directlyto that insurer.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Skilled Nursing Facility (SNF) stay not covered when care is primarilyrelated to the use of an urethral catheter for convenience or the controlof incontinence.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)SSA records indicate mismatch with name and sex.Start: 01/01/1997Payment of less than $1.00 suppressed.Start: 01/01/1997Demand bill approved as result of medical review.Start: 01/01/199720

ReasonCodesMA24MA25MA26MA27MA28MA30MA31DescriptionChristian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in thesame benefit period.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)A patient may not elect to change a hospice provider more than once ina benefit period.Start: 01/01/1997Alert: Our records indicate that you were previously informed of thisrule.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid entitlement number or name shown on theclaim.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Alert: Receipt of this notice by a physician or supplier who did notaccept assignment is for information only and does not make thephysician or supplier a party to the determination. No additional rightsto appeal this decision, above those rights already provided for byregulation/instruction, are conferred by receipt of this notice.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid type of bill.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid beginning and ending dates of the periodbilled.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)21

ReasonCodesMA32MA33MA34MA35MA36MA37MA39MA40MA41DescriptionMissing/incomplete/invalid number of covered days during the billingperiod.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid noncovered days during the billing period.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of coinsurance days during thebilling period.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of lifetime reserve days.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient name.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient's address.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid gender.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid admission date.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid admission type.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)22

ReasonCodesMA42MA43MA44MA45MA46MA47MA48MA50DescriptionMissing/incomplete/invalid admission source.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient status.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Alert: No appeal rights. Adjudicative decision based on law.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: As previously advised, a portion or all of your payment is beingheld in a special account.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The new information was considered but additional payment will not beissued.Start: 01/01/1997 | Last Modified: 03/01/2009Notes: (Modified 3/1/2009)Our records show you have opted out of Medicare, agreeing with thepatient not to bill Medicare for services/tests/supplies furnished. Asresult, we cannot pay this claim. The patient is responsible for payment.Start: 01/01/1997Missing/incomplete/invalid name or address of responsible party orprimary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid Investigational Device Exemption number forFDA-approved clinical trial services.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)23

ReasonCodesMA53MA54MA55MA56MA57MA58MA59DescriptionMissing/incomplete/invalid Competitive Bidding Demonstration Projectidentification.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)Physician certification or election consent for hospice care not receivedtimely.Start: 01/01/1997Not covered as patient received medical health care services,automatically revoking his/her election to receive religious non-medicalhealth care services.Start: 01/01/1997Our records show you have opted out of Medicare, agreeing with thepatient not to bill Medicare for services/tests/supplies furnished. Asresult, we cannot pay this claim. The patient is responsible for payment,but under Federal law, you cannot charge the patient more than thelimiting charge amount.Start: 01/01/1997Patient submitted written request to revoke his/her election for religiousnon-medical health care services.Start: 01/01/1997Missing/incomplete/invalid release of information indicator.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Alert: The patient overpaid you for these services. You must issue thepatient a refund within 30 days for the difference between his/herpayment and the total amount shown as patient responsibility on thisnotice.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)24

ReasonCodesMA60MA61MA62MA63MA64MA65MA66MA67DescriptionMissing/incomplete/invalid patient relationship to insured.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid social security number or health insuranceclaim number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Alert: This is a telephone review decision.Start: 01/01/1997 | Last Modified: 08/01/2007Notes: (Modified 4/1/07, 8/1/07)Missing/incomplete/invalid principal diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Our records indicate that we should be the third payer for this claim. Wecannot process this claim until we have received payment informationfrom the primary and secondary payers.Start: 01/01/1997Missing/incomplete/invalid admitting diagnosis.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid principal procedure code.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N303Correction to a prior claim.Start: 01/01/199725

ReasonCodesMA68MA69MA70MA71MA72MA73MA74DescriptionAlert: We did not crossover this claim because the secondary insuranceinformation on the claim was incomplete. Please supply completeinformation or use the PLANID of the insurer to assure correct andtimely routing of the claim.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid remarks.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid provider representative signature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid provider representative signature date.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Alert: The patient overpaid you for these assigned services. You mustissue the patient a refund within 30 days for the difference betweenhis/her payment to you and the total of the amount shown as patientresponsibility and as paid to the patient on this notice.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Informational remittance associated with a Medicare demonstration. Nopayment issued under fee-for-service Medicare as patient has electedmanaged care.Start: 01/01/1997This payment replaces an earlier payment for this claim that was eitherlost, damaged or returned.Start: 01/01/199726

ReasonCodesMA75MA76MA77MA79MA80MA81MA83DescriptionMissing/incomplete/invalid patient or authorized representativesignature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid provider identifier for home health agency orhospice when physician is performing care plan oversight services.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03, 2/1/04)Alert: The patient overpaid you. You must issue the patient a refundwithin 30 days for the difference between the patient's payment less thetotal of our and other payer payments and the amount shown as patientresponsibility on this notice.Start: 01/01/1997 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Billed in excess of interim rate.Start: 01/01/1997Informational notice. No payment issued for this claim with this notice.Payment issued to the hospital by its intermediary for all services forthis encounter under a demonstration project.Start: 01/01/1997Missing/incomplete/invalid provider/supplier signature.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Did not indicate whether we are the primary or secondary payer.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)27

ReasonCodesMA84MA88MA89MA90MA91MA92MA93DescriptionPatient identified as participating in the National Emphysema TreatmentTrial but our records indicate that this patient is either not a participant,or has not yet been approved for this phase of the study. Contact JohnsHopkins University, the study coordinator, to resolve if there was adiscrepancy.Start: 01/01/1997Missing/incomplete/invalid insured's address and/or telephone numberfor the primary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid patient's relationship to the insured for theprimary payer.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid employment status code for the primaryinsured.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03).This determination is the result of the appeal you filed.Start: 01/01/1997Missing plan information for other insurance.Start: 01/01/1997 | Last Modified: 02/01/2004Notes: (Modified 2/1/04) Related to N245Non-PIP (Periodic Interim Payment) claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)28

ReasonDescriptionCodesMA94 Did not enter the statement "Attending physician not hospiceemployee" on the claim form to certify that the rendering physician isnot an employee of the hospice.Start: 01/01/1997 | Last Modified: 08/01/2005Notes: (Reactivated 4/1/04, Modified 8/1/05)MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration butpatient is not enrolled in a Medicare managed care plan.Start: 01/01/1997MA97 Missing/incomplete/invalid Medicare Managed Care Demonstrationcontract number or clinical trial registry number.Start: 01/01/1997 | Last Modified: 02/29/2008Notes: (Modified 2/29/08)MA99 Missing/incomplete/invalid Medigap information.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)MA100 Missing/incomplete/invalid date of current illness or symptomsStart: 01/01/1997 | Last Modified: 03/30/2005Notes: (Modified 2/28/03, 3/30/05)MA101 A Skilled Nursing Facility (SNF) is responsible for payment of outsideproviders who furnish these services/supplies to residents.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)MA103 Hemophilia Add On.Start: 01/01/1997MA106 PIP (Periodic Interim Payment) claim.Start: 01/01/1997 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)MA107 Paper claim contains more than three separate data items in field 19.Start: 01/01/199729

ReasonDescriptionCodesMA108 Paper claim contains more than one data item in field 23.Start: 01/01/1997MA109 Claim processed in accordance with ambulatory surgical guidelines.Start: 01/01/1997MA110 Missing/incomplete/invalid information on whether the diagnostic test(s)were performed by an outside entity or if no purchased tests areincluded on the claim.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)MA111 Missing/incomplete/invalid purchase price of the test(s) and/or theperforming laboratory's name and address.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)MA112 Missing/incomplete/invalid group practice information.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)MA113 Incomplete/invalid taxpayer identification number (TIN) submitted byyou per the Internal Revenue Service. Your claims cannot be processedwithout your correct TIN, and you may not bill the patient pendingcorrection of your TIN. There are no appeal rights for unprocessableclaims, but you may resubmit this claim after you have notified thisoffice of your correct TIN.Start: 01/01/1997MA114 Missing/incomplete/invalid information on where the services werefurnished.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)30

ReasonCodesMA115MA116MA117MA118MA120MA121MA122MA123DescriptionMissing/incomplete/invalid physical location (name and address, or PIN)where the service(s) were rendered in a Health Professional ShortageArea (HPSA).Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Did not complete the statement 'Homebound' on the claim to validatewhether laboratory services were performed at home or in an institution.Start: 01/01/1997Notes: (Reactivated 4/1/04)This claim has been assessed a $1.00 user fee.Start: 01/01/1997Coinsurance and/or deductible amounts apply to a claim for services orsupplies furnished to a Medicare-eligible veteran through a facility ofthe Department of Veterans Affairs. No Medicare payment issued.Start: 01/01/1997Missing/incomplete/invalid CLIA certification number.Start: 01/01/1997 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid x-ray date.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Missing/incomplete/invalid initial treatment date.Start: 01/01/1997 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Your center was not selected to participate in this study, therefore, wecannot pay for these services.Start: 01/01/199731

ReasonCodesMA125MA126MA128MA130MA131MA132MA133MA134N1DescriptionPer legislation governing this program, payment constitutes payment infull.Start: 01/01/1997Pancreas transplant not covered unless kidney transplant performed.Start: 10/12/2001Missing/incomplete/invalid FDA approval number.Start: 10/12/2001 | Last Modified: 03/30/2005Notes: (Modified 2/28/03, 3/30/05)Your claim contains incomplete and/or invalid information, and noappeal rights are afforded because the claim is unprocessable. Pleasesubmit a new claim with the complete/correct information.Start: 10/12/2001Physician already paid for services in conjunction with thisdemonstration claim. You must have the physician withdraw that claimand refund the payment before we can process your claim.Start: 10/12/2001Adjustment to the pre-demonstration rate.Start: 10/12/2001Claim overlaps inpatient stay. Rebill only those services renderedoutside the inpatient stay.Start: 10/12/2001Missing/incomplete/invalid provider number of the facility where thepatient resides.Start: 10/12/2001Alert: You may appeal this decision in writing within the required timelimits following receipt of this notice by following the instructionsincluded in your contract or plan benefit documents.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 2/28/03, 4/1/07)32

ReasonCodesN2N3N4N5N6N7N8N9DescriptionThis allowance has been made in accordance with the most appropriatecourse of treatment provision of the plan.Start: 01/01/2000Missing consent form.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03) Related to N228Missing/incomplete/invalid prior insurance carrier EOB.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)EOB received from previous payer. Claim not on file.Start: 01/01/2000Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered carethan the amount Medicare would have allowed if the patient wereenrolled in Medicare Part A and/or Medicare Part B.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Processing of this claim/service has included consideration under MajorMedical provisions.Start: 01/01/2000Crossover claim denied by previous payer and complete claim data notforwarded. Resubmit this claim to this payer to provide adequate datafor adjudication.Start: 01/01/2000Adjustment represents the estimated amount a previous payer may pay.Start: 01/01/2000 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)33

ReasonCodesN10N11N12N13N15N16N19N20N21DescriptionPayment based on the findings of a review organization/professionalconsult/manual adjudication/medical or dental advisor.Start: 01/01/2000 | Last Modified: 07/01/2008Notes: (Modified 10/31/02, 7/1/08)Denial reversed because of medical review.Start: 01/01/2000Policy provides coverage supplemental to Medicare. As the memberdoes not appear to be enrolled in the applicable part of Medicare, themember is responsible for payment of the portion of the charge thatwould have been covered by Medicare.Start: 01/01/2000 | Last Modified: 08/01/2007Notes: (Modified 8/1/07)Payment based on professional/technical component modifier(s).Start: 01/01/2000Services for a newborn must be billed separately.Start: 01/01/2000Family/member Out-of-Pocket maximum has been met. Payment basedon a higher percentage.Start: 01/01/2000Procedure code incidental to primary procedure.Start: 01/01/2000Service not payable with other service rendered on the same date.Start: 01/01/2000Alert: Your line item has been separated into multiple lines to expeditehandling.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 8/1/05, 4/1/07)34

ReasonCodesN22N23N24N25N26N27N28N29DescriptionThis procedure code was added/changed because it more accuratelydescribes the services rendered.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 10/31/02, 2/28/03)Alert: Patient liability may be affected due to coordination of benefitswith other carriers and/or maximum benefit provisions.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 8/13/01, 4/1/07)Missing/incomplete/invalid Electronic Funds Transfer (EFT) bankinginformation.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)This company has been contracted by your benefit plan to provideadministrative claims payment services only. This company does notassume financial risk or obligation with respect to claims processed onbehalf of your benefit plan.Start: 01/01/2000Missing itemized bill/statement.Start: 01/01/2000 | Last Modified: 07/01/2008Notes: (Modified 2/28/03, 7/1/2008) Related to N232Missing/incomplete/invalid treatment number.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Consent form requirements not fulfilled.Start: 01/01/2000Missing documentation/orders/notes/summary/report/chart.Start: 01/01/2000 | Last Modified: 08/01/2005Notes: (Modified 2/28/03, 8/1/05) Related to N22535

ReasonCodesN30N31N32N33N34N35N36N37N39N40N42DescriptionPatient ineligible for this service.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Missing/incomplete/invalid prescribing provider identifier.Start: 01/01/2000 | Last Modified: 12/02/2004Notes: (Modified 12/2/04)Claim must be submitted by the provider who rendered the service.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)No record of health check prior to initiation of treatment.Start: 01/01/2000Incorrect claim form/format for this service.Start: 01/01/2000 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)Program integrity/utilization review decision.Start: 01/01/2000Claim must meet primary payer's processing requirements before wecan consider payment.Start: 01/01/2000Missing/incomplete/invalid tooth number/letter.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Procedure code is not compatible with tooth number/letter.Start: 01/01/2000Missing radiology film(s)/image(s).Start: 01/01/2000 | Last Modified: 07/01/2008Notes: (Modified 2/1/04, 7/1/08) Related to N242No record of mental health assessment.Start: 01/01/200036

ReasonCodesN43N45N46N47N48N49N50N51N52N53N54N55DescriptionBed hold or leave days exceeded.Start: 01/01/2000Payment based on authorized amount.Start: 01/01/2000Missing/incomplete/invalid admission hour.Start: 01/01/2000Claim conflicts with another inpatient stay.Start: 01/01/2000Claim information does not agree with information received from otherinsurance carrier.Start: 01/01/2000Court ordered coverage information needs validation.Start: 01/01/2000Missing/incomplete/invalid discharge information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Electronic interchange agreement not on file for provider/submitter.Start: 01/01/2000Patient not enrolled in the billing provider's managed care plan on thedate of service.Start: 01/01/2000Missing/incomplete/invalid point of pick-up address.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Claim information is inconsistent with pre-certified/authorized services.Start: 01/01/2000Procedures for billing with group/referring/performing providers werenot followed.Start: 01/01/200037

ReasonCodesN56N57N58N59N61N62N63N64N65DescriptionProcedure code billed is not correct/valid for the services billed or thedate of service billed.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid prescribing date.Start: 01/01/2000 | Last Modified: 12/02/2004Notes: (Modified 12/2/04) Related to N304Missing/incomplete/invalid patient liability amount.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Please refer to your provider manual for additional program andprovider information.Start: 01/01/2000 | Last Modified: 11/01/2009Notes: (Modified 4/1/07, 11/1/09)Rebill services on separate claims.Start: 01/01/2000Inpatient admission spans multiple rate periods. Resubmit separateclaims.Start: 01/01/2000Rebill services on separate claim lines.Start: 01/01/2000The "from" and "to" dates must be different.Start: 01/01/2000Procedure code or procedure rate count cannot be determined, or wasnot on file, for the date of service/provider.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)38

ReasonCodesN67N68N69N70DescriptionProfessional provider services not paid separately. Included in facilitypayment under a demonstration project. Apply to that facility forpayment, or resubmit your claim if: the facility notifies you the patientwas excluded from this demonstration; or if you furnished theseservices in another location on the date of the patient's admission ordischarge from a demonstration hospital. If services were furnished in afacility not involved in the demonstration on the same date the patientwas discharged from or admitted to a demonstration facility, you mustreport the provider ID number for the non-demonstration facility on thenew claim.Start: 01/01/2000Prior payment being cancelled as we were subsequently notified thispatient was covered by a demonstration project in this site of service.Professional services were included in the payment made to the facility.You must contact the facility for your payment. Prior payment made toyou by the patient or another insurer for this claim must be refunded tothe payer within 30 days.Start: 01/01/2000PPS (Prospective Payment System) code changed by claims processingsystem. Insufficient visits or therapies.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Consolidated billing and payment applies.Start: 01/01/2000 | Last Modified: 11/05/2007Notes: (Modified 2/28/02, 11/5/07)39

ReasonCodesN71N72N74N75N76N77N78N79DescriptionYour unassigned claim for a drug or biological, clinical diagnosticlaboratory services or ambulance service was processed as anassigned claim. You are required by law to accept assignment for thesetypes of claims.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 2/21/02, 6/30/03)PPS (Prospective Payment System) code changed by medicalreviewers. Not supported by clinical records.Start: 01/01/2000 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Resubmit with multiple claims, each claim covering services provided inonly one calendar month.Start: 01/01/2000Missing/incomplete/invalid tooth surface information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid number of riders.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Missing/incomplete/invalid designated provider number.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)The necessary components of the child and teen checkup (EPSDT) werenot completed.Start: 01/01/2000Service billed is not compatible with patient location information.Start: 01/01/200040

ReasonCodesN80N81N82N83N84N85N86N87DescriptionMissing/incomplete/invalid prenatal screening information.Start: 01/01/2000 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)Procedure billed is not compatible with tooth surface code.Start: 01/01/2000Provider must accept insurance payment as payment in full when a thirdparty payer contract specifies full reimbursement.Start: 01/01/2000No appeal rights. Adjudicative decision based on the provisions of ademonstration project.Start: 01/01/2000Alert: Further installment payments are forthcoming.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 4/1/07, 8/1/07)Alert: This is the final installment payment.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 4/1/07, 8/1/07)A failed trial of pelvic muscle exercise training is required in order forbiofeedback training for the treatment of urinary incontinence to becovered.Start: 01/01/2000Home use of biofeedback therapy is not covered.Start: 01/01/200041

ReasonCodesN88N89N90N91N92N93N94N95DescriptionAlert: This payment is being made conditionally. An HHA episode ofcare notice has been filed for this patient. When a patient is treatedunder a HHA episode of care, consolidated billing requires that certaintherapy services and supplies, such as this, be included in the HHA'spayment. This payment will need to be recouped from you if weestablish that the patient is concurrently receiving treatment under aHHA episode of care.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Payment information for this claim has been forwarded to morethan one other payer, but format limitations permit only one of thesecondary payers to be identified in this remittance advice.Start: 01/01/2000 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Covered only when performed by the attending physician.Start: 01/01/2000Services not included in the appeal review.Start: 01/01/2000This facility is not certified for digital mammography.Start: 01/01/2000A separate claim must be submitted for each place of service. Servicesfurnished at multiple sites may not be billed in the same claim.Start: 01/01/2000Claim/Service denied because a more specific taxonomy code isrequired for adjudication.Start: 01/01/2000This provider type/provider specialty may not bill this service.Start: 07/31/2001 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)42

ReasonCodesN96N97N98N99N100N102DescriptionPatient must be refractory to conventional therapy (documentedbehavioral, pharmacologic and/or surgical corrective therapy) and be anappropriate surgical candidate such that implantation with anesthesiacan occur.Start: 08/24/2001Patients with stress incontinence, urinary obstruction, and specificneurologic diseases (e.g., diabetes with peripheral nerve involvement)which are associated with secondary manifestations of the above threeindications are excluded.Start: 08/24/2001Patient must have had a successful test stimulation in order to supportsubsequent implantation. Before a patient is eligible for permanentimplantation, he/she must demonstrate a 50 percent or greaterimprovement through test stimulation. Improvement is measuredthrough voiding diaries.Start: 08/24/2001Patient must be able to demonstrate adequate ability to record voidingdiary data such that clinical results of the implant procedure can beproperly evaluated.Start: 08/24/2001PPS (Prospect Payment System) code corrected during adjudication.Start: 09/14/2001 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)This claim has been denied without reviewing the medical recordbecause the requested records were not received or were not receivedtimely.Start: 10/31/200143

ReasonCodesN103N104N105N106N107DescriptionSocial Security records indicate that this patient was a prisoner whenthe service was rendered. This payer does not cover items and servicesfurnished to an individual while they are in State or local custody undera penal authority, unless under State or local law, the individual ispersonally liable for the cost of his or her health care while incarceratedand the State or local government pursues such debt in the same wayand with the same vigor as any other debt.Start: 10/31/2001 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)This claim/service is not payable under our claims jurisdiction area. Youcan identify the correct Medicare contractor to process thisclaim/service through the CMS website at www.cms.hhs.gov.Start: 01/29/2002 | Last Modified: 10/31/2002Notes: (Modified 10/31/02)This is a misdirected claim/service for an RRB beneficiary. Submit paperclaims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA30999. Call 866-749-4301 for RRB EDI information for electronic claimsprocessing.Start: 01/29/2002Payment for services furnished to Skilled Nursing Facility (SNF)inpatients (except for excluded services) can only be made to the SNF.You must request payment from the SNF rather than the patient for thisservice.Start: 01/31/2002Services furnished to Skilled Nursing Facility (SNF) inpatients must bebilled on the inpatient claim. They cannot be billed separately asoutpatient services.Start: 01/31/200244

ReasonCodesN108N109N110N111N112N113N114DescriptionMissing/incomplete/invalid upgrade information.Start: 01/31/2002 | Last Modified: 02/28/2003Notes: (Modified 2/28/03)This claim/service was chosen for complex review and was denied afterreviewing the medical records.Start: 02/28/2002 | Last Modified: 03/01/2009Notes: (Modified 3/1/2009)This facility is not certified for film mammography.Start: 02/28/2002No appeal right except duplicate claim/service issue. This service wasincluded in a claim that has been previously billed and adjudicated.Start: 02/28/2002This claim is excluded from your electronic remittance advice.Start: 02/28/2002Only one initial visit is covered per physician, group practice orprovider.Start: 04/16/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)During the transition to the Ambulance Fee Schedule, payment is basedon the lesser of a blended amount calculated using a percentage of thereasonable charge/cost and fee schedule amounts, or the submittedcharge for the service. You will be notified yearly what the percentagesfor the blended payment calculation will be.Start: 05/30/200245

ReasonCodesN115N116N117N118N119DescriptionThis decision was based on a local medical review policy (LMRP) orLocal Coverage Determination (LCD).An LMRP/LCD provides a guide toassist in determining whether a particular item or service is covered. Acopy of this policy is available at http://www.cms.hhs.gov/mcd, or if youdo not have web access, you may contact the contractor to request acopy of the LMRP/LCD.Start: 05/30/2002 | Last Modified: 04/01/2004Notes: (Modified 4/1/04)This payment is being made conditionally because the service wasprovided in the home, and it is possible that the patient is under a homehealth episode of care. When a patient is treated under a home healthepisode of care, consolidated billing requires that certain therapyservices and supplies, such as this, be included in the home healthagency's (HHA's) payment. This payment will need to be recouped fromyou if we establish that the patient is concurrently receiving treatmentunder an HHA episode of care.Start: 06/30/2002This service is paid only once in a patient's lifetime.Start: 07/30/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)This service is not paid if billed more than once every 28 days.Start: 07/30/2002This service is not paid if billed once every 28 days, and the patient hasspent 5 or more consecutive days in any inpatient or Skilled /nursingFacility (SNF) within those 28 days.Start: 07/30/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)46

ReasonCodesN120N121N122N123N124DescriptionPayment is subject to home health prospective payment system partialepisode payment adjustment. Patient wastransferred/discharged/readmitted during payment episode.Start: 08/09/2002 | Last Modified: 06/30/2003Notes: (Modified 6/30/03)Medicare Part B does not pay for items or services provided by this typeof practitioner for beneficiaries in a Medicare Part A covered SkilledNursing Facility (SNF) stay.Start: 09/09/2002 | Last Modified: 08/01/2004Notes: (Modified 8/1/04, 6/30/03)Add-on code cannot be billed by itself.Start: 09/12/2002 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)This is a split service and represents a portion of the units from theoriginally submitted service.Start: 09/24/2002Payment has been denied for the/made only for a less extensiveservice/item because the information furnished does not substantiatethe need for the (more extensive) service/item. The patient is liable forthe charges for this service/item as you informed the patient in writingbefore the service/item was furnished that we would not pay for it, andthe patient agreed to pay.Start: 09/26/200247

ReasonCodesN125DescriptionPayment has been (denied for the/made only for a less extensive)service/item because the information furnished does not substantiatethe need for the (more extensive) service/item. If you have collected anyamount from the patient, you must refund that amount to the patientwithin 30 days of receiving this notice.N126N127N128N129The requirements for a refund are in 1834(a)(18) of the Social SecurityAct (and in 1834(j)(4) and 1879(h) by cross-reference to 1834(a)(18)).Section 1834(a)(18)(B) specifies that suppliers which knowingly andwillfully fail to make appropriate refunds may be subject to civil moneypenalties and/or exclusion from the Medicare program. If you have anyquestions about this notice, please contact this office.Start: 09/26/2002 | Last Modified: 08/01/2005Notes: (Modified 8/1/05. Also refer to N356)Social Security Records indicate that this individual has been deported.This payer does not cover items and services furnished to individualswho have been deported.Start: 10/17/2002This is a misdirected claim/service for a United Mine Workers ofAmerica (UMWA) beneficiary. Please submit claims to them.Start: 10/31/2007 | Last Modified: 08/01/2004Notes: (Modified 8/1/04This amount represents the prior to coverage portion of the allowance.Start: 10/31/2002Not eligible due to the patient's age.Start: 10/31/2002 | Last Modified: 08/01/2007Notes: (Modified 8/1/07)48

ReasonCodesN130N131N132N133N134N135N136DescriptionConsult plan benefit documents/guidelines for information aboutrestrictions for this service.Start: 10/31/2002 | Last Modified: 11/01/2009Notes: (Modified 4/1/07, 7/1/08, 11/1/09)Total payments under multiple contracts cannot exceed the allowancefor this service.Start: 10/31/2002Alert: Payments will cease for services rendered by this US Governmentdebarred or excluded provider after the 30 day grace period aspreviously notified.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Services for predetermination and services requesting paymentare being processed separately.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: This represents your scheduled payment for this service. Iftreatment has been discontinued, please contact Customer Service.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Record fees are the patient's responsibility and limited to the specifiedco-payment.Start: 10/31/2002Alert: To obtain information on the process to file an appeal in Arizona,call the Department's Consumer Assistance Office at (602) 912-8444 or(800) 325-2548.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)49

ReasonCodesN137N138N139DescriptionAlert: The provider acting on the Member's behalf, may file an appealwith the Payer. The provider, acting on the Member's behalf, may file acomplaint with the State Insurance Regulatory Authority without firstfiling an appeal, if the coverage decision involves an urgent conditionfor which care has not been rendered. The address may be obtainedfrom the State Insurance Regulatory Authority.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 8/1/04, 2/28/03, 4/1/07)Alert: In the event you disagree with the Dental Advisor's opinion andhave additional information relative to the case, you may submitradiographs to the Dental Advisor Unit at the subscriber's dentalinsurance carrier for a second Independent Dental Advisor Review.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Under the Code of Federal Regulations, Chapter 32, Section199.13 a non-participating provider is not an appropriate appealingparty. Therefore, if you disagree with the Dental Advisor's opinion, youmay appeal the determination if appointed in writing, by the beneficiary,to act as his/her representative. Should you be appointed as arepresentative, submit a copy of this letter, a signed statementexplaining the matter in which you disagree, and any radiographs andrelevant information to the subscriber's Dental insurance carrier within90 days from the date of this letter.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)50

ReasonCodesN140N141N142N143N144N146N147DescriptionAlert: You have not been designated as an authorized OCONUS providertherefore are not considered an appropriate appealing party. If thebeneficiary has appointed you, in writing, to act as his/herrepresentative and you disagree with the Dental Advisor's opinion, youmay appeal by submitting a copy of this letter, a signed statementexplaining the matter in which you disagree, and any relevantinformation to the subscriber's Dental insurance carrier within 90 daysfrom the date of this letter.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The patient was not residing in a long-term care facility during all or partof the service dates billed.Start: 10/31/2002The original claim was denied. Resubmit a new claim, not a replacementclaim.Start: 10/31/2002The patient was not in a hospice program during all or part of theservice dates billed.Start: 10/31/2002The rate changed during the dates of service billed.Start: 10/31/2002Missing screening document.Start: 10/31/2002 | Last Modified: 08/01/2004Notes: (Modified 8/1/04) Related to N243Long term care case mix or per diem rate cannot be determinedbecause the patient ID number is missing, incomplete, or invalid on theassignment request.Start: 10/31/200251

ReasonCodesN148N149N150N151N152N153N154N155N156N157DescriptionMissing/incomplete/invalid date of last menstrual period.Start: 10/31/2002Rebill all applicable services on a single claim.Start: 10/31/2002Missing/incomplete/invalid model number.Start: 10/31/2002Telephone contact services will not be paid until the face-to-facecontact requirement has been met.Start: 10/31/2002Missing/incomplete/invalid replacement claim information.Start: 10/31/2002Missing/incomplete/invalid room and board rate.Start: 10/31/2002Alert: This payment was delayed for correction of provider's mailingaddress.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Our records do not indicate that other insurance is on file. Pleasesubmit other insurance information for our records.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: The patient is responsible for the difference between theapproved treatment and the elective treatment.Start: 10/31/2002 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Transportation to/from this destination is not covered.Start: 02/28/2003 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)52

ReasonCodesN158N159N160N161N162N163N167N170N171DescriptionTransportation in a vehicle other than an ambulance is not covered.Start: 02/28/2003Payment denied/reduced because mileage is not covered when thepatient is not in the ambulance.Start: 02/28/2003The patient must choose an option before a payment can be made forthis procedure/ equipment/ supply/ service.Start: 02/28/2003 | Last Modified: 02/01/2004Notes: (Modified 2/1/04)This drug/service/supply is covered only when the associated service iscovered.Start: 02/28/2003Alert: Although your claim was paid, you have billed for a test/specialtynot included in your Laboratory Certification. Your failure to correct thelaboratory certification information will result in a denial of payment inthe near future.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Medical record does not support code billed per the code definition.Start: 02/28/2003Charges exceed the post-transplant coverage limit.Start: 02/28/2003A new/revised/renewed certificate of medical necessity is needed.Start: 02/28/2003Payment for repair or replacement is not covered or has exceeded thepurchase price.Start: 02/28/200353

ReasonCodesN172N173N174N175N176N177N178N179DescriptionThe patient is not liable for the denied/adjusted charge(s) for receivingany updated service/item.Start: 02/28/2003No qualifying hospital stay dates were provided for this episode of care.Start: 02/28/2003This is not a covered service/procedure/ equipment/bed, howeverpatient liability is limited to amounts shown in the adjustments undergroup 'PR'.Start: 02/28/2003Missing review organization approval.Start: 02/28/2003 | Last Modified: 02/29/2008Notes: (Modified 8/1/04, 2/29/08) Related to N241Services provided aboard a ship are covered only when the ship is ofUnited States registry and is in United States waters. In addition, adoctor licensed to practice in the United States must provide theservice.Start: 02/28/2003Alert: We did not send this claim to patient's other insurer. They haveindicated no additional payment can be made.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 6/30/03, 4/1/07)Missing pre-operative photos or visual field results.Start: 02/28/2003 | Last Modified: 08/01/2004Notes: (Modified 8/1/04) Related to N244Additional information has been requested from the member. Thecharges will be reconsidered upon receipt of that information.Start: 02/28/200354

ReasonCodesN180N181N182N183N184N185N186N187DescriptionThis item or service does not meet the criteria for the category underwhich it was billed.Start: 02/28/2003Additional information is required from another provider involved in thisservice.Start: 02/28/2003 | Last Modified: 12/01/2006Notes: (Modified 12/1/06)This claim/service must be billed according to the schedule for thisplan.Start: 02/28/2003Alert: This is a predetermination advisory message, when this service issubmitted for payment additional documentation as specified in plandocuments will be required to process benefits.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Rebill technical and professional components separately.Start: 02/28/2003Alert: Do not resubmit this claim/service.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Non-Availability Statement (NAS) required for this service. Contact thenearest Military Treatment Facility (MTF) for assistance.Start: 02/28/2003Alert: You may request a review in writing within the required time limitsfollowing receipt of this notice by following the instructions included inyour contract or plan benefit documents.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)55

ReasonCodesN188N189N190N191N192N193N194N195N196N197N198DescriptionThe approved level of care does not match the procedure codesubmitted.Start: 02/28/2003Alert: This service has been paid as a one-time exception to the plan'sbenefit restrictions.Start: 02/28/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing contract indicator.Start: 02/28/2003 | Last Modified: 08/01/2004Notes: (Modified 8/1/04) Related to N229The provider must update insurance information directly with payer.Start: 02/28/2003Patient is a Medicaid/Qualified Medicare Beneficiary.Start: 02/28/2003Specific federal/state/local program may cover this service throughanother payer.Start: 02/28/2003Technical component not paid if provider does not own the equipmentused.Start: 02/25/2003The technical component must be billed separately.Start: 02/25/2003Alert: Patient eligible to apply for other coverage which may be primary.Start: 02/25/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The subscriber must update insurance information directly with payer.Start: 02/25/2003Rendering provider must be affiliated with the pay-to provider.Start: 02/25/200356

ReasonCodesN199N200N201N202N203N204N205N206N207N208N209DescriptionAdditional payment/recoupment approved based on payer-initiatedreview/audit.Start: 02/25/2003 | Last Modified: 08/01/2006Notes: (Modified 8/1/06)The professional component must be billed separately.Start: 02/25/2003A mental health facility is responsible for payment of outside providerswho furnish these services/supplies to residents.Start: 02/25/2003Additional information/explanation will be sent separatelyStart: 06/30/2003 | Last Modified: 11/01/2009Notes: (Modified 4/1/07, 11/1/09)Missing/incomplete/invalid anesthesia time/unitsStart: 06/30/2003Services under review for possible pre-existing condition. Send medicalrecords for prior 12 monthsStart: 06/30/2003Information provided was illegibleStart: 06/30/2003The supporting documentation does not match the claimStart: 06/30/2003Missing/incomplete/invalid weight.Start: 06/30/2003 | Last Modified: 11/18/2005Notes: (Modified 11/18/05)Missing/incomplete/invalid DRG codeStart: 06/30/2003Missing/incomplete/invalid taxpayer identification number (TIN).Start: 06/30/2003 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)57

ReasonCodesN210N211N212N213N214N215N216N217N218N219DescriptionAlert: You may appeal this decisionStart: 06/30/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: You may not appeal this decisionStart: 06/30/2003 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Charges processed under a Point of Service benefitStart: 02/01/2004Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt statusinformationStart: 04/01/2004Missing/incomplete/invalid history of the related initial surgicalprocedure(s)Start: 04/01/2004Alert: A payer providing supplemental or secondary coverage shall notrequire a claims determination for this service from a primary payer as acondition of making its own claims determination.Start: 04/01/2004 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Patient is not enrolled in this portion of our benefit packageStart: 04/01/2004We pay only one site of service per provider per claimStart: 08/01/2004You must furnish and service this item for as long as the patientcontinues to need it. We can pay for maintenance and/or servicing forthe time period specified in the contract or coverage manual.Start: 08/01/2004Payment based on previous payer's allowed amount.Start: 08/01/200458

ReasonCodesN220N221N222N223N224N225N226N227N228N229DescriptionAlert: See the payer's web site or contact the payer's Customer Servicedepartment to obtain forms and instructions for filing a providerdispute.Start: 08/01/2004 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing Admitting History and Physical report.Start: 08/01/2004Incomplete/invalid Admitting History and Physical report.Start: 08/01/2004Missing documentation of benefit to the patient during initial treatmentperiod.Start: 08/01/2004Incomplete/invalid documentation of benefit to the patient during initialtreatment period.Start: 08/01/2004Incomplete/invalid documentation/orders/notes/summary/report/chart.Start: 08/01/2004 | Last Modified: 08/01/2005Notes: (Modified 8/1/05)Incomplete/invalid American Diabetes Association Certificate ofRecognition.Start: 08/01/2004Incomplete/invalid Certificate of Medical Necessity.Start: 08/01/2004Incomplete/invalid consent form.Start: 08/01/2004Incomplete/invalid contract indicator.Start: 08/01/200459

ReasonCodesN230N231N232N233N234N235N236N237N238N239N240N241DescriptionIncomplete/invalid indication of whether the patient owns the equipmentthat requires the part or supply.Start: 08/01/2004Incomplete/invalid invoice or statement certifying the actual cost of thelens, less discounts, and/or the type of intraocular lens used.Start: 08/01/2004Incomplete/invalid itemized bill/statement.Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid operative note/report.Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid oxygen certification/re-certification.Start: 08/01/2004Incomplete/invalid pacemaker registration form.Start: 08/01/2004Incomplete/invalid pathology report.Start: 08/01/2004Incomplete/invalid patient medical record for this service.Start: 08/01/2004Incomplete/invalid physician certified plan of careStart: 08/01/2004Incomplete/invalid physician financial relationship form.Start: 08/01/2004Incomplete/invalid radiology report.Start: 08/01/2004Incomplete/invalid review organization approval.Start: 08/01/2004 | Last Modified: 02/29/2008Notes: (Modified 2/29/08)60

ReasonCodesN242N243N244N245N246N247N248N249N250N251N252N253N254N255DescriptionIncomplete/invalid radiology film(s)/image(s).Start: 08/01/2004 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Incomplete/invalid/not approved screening document.Start: 08/01/2004Incomplete/invalid pre-operative photos/visual field results.Start: 08/01/2004Incomplete/invalid plan information for other insuranceStart: 08/01/2004State regulated patient payment limitations apply to this service.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon taxonomy.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon name.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon primary identifier.Start: 12/02/2004Missing/incomplete/invalid assistant surgeon secondary identifier.Start: 12/02/2004Missing/incomplete/invalid attending provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid attending provider name.Start: 12/02/2004Missing/incomplete/invalid attending provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid attending provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider taxonomy.Start: 12/02/200461

ReasonCodesN256N257N258N259N260N261N262N263N264N265N266N267N268N269DescriptionMissing/incomplete/invalid billing provider/supplier name.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier primary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier address.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier secondary identifier.Start: 12/02/2004Missing/incomplete/invalid billing provider/supplier contact information.Start: 12/02/2004Missing/incomplete/invalid operating provider name.Start: 12/02/2004Missing/incomplete/invalid operating provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid operating provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider name.Start: 12/02/2004Missing/incomplete/invalid ordering provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider address.Start: 12/02/2004Missing/incomplete/invalid ordering provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid ordering provider contact information.Start: 12/02/2004Missing/incomplete/invalid other provider name.Start: 12/02/200462

ReasonCodesN270N271N272N273N274N275N276N277N278N279N280N281N282DescriptionMissing/incomplete/invalid other provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid other provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid other payer attending provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer operating provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer other provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer purchased service provideridentifier.Start: 12/02/2004Missing/incomplete/invalid other payer referring provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer rendering provider identifier.Start: 12/02/2004Missing/incomplete/invalid other payer service facility provideridentifier.Start: 12/02/2004Missing/incomplete/invalid pay-to provider name.Start: 12/02/2004Missing/incomplete/invalid pay-to provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid pay-to provider address.Start: 12/02/2004Missing/incomplete/invalid pay-to provider secondary identifier.Start: 12/02/200463

ReasonCodesN283N284N285N286N287N288N289N290N291N292N293N294N295N296DescriptionMissing/incomplete/invalid purchased service provider identifier.Start: 12/02/2004Missing/incomplete/invalid referring provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid referring provider name.Start: 12/02/2004Missing/incomplete/invalid referring provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid referring provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid rendering provider taxonomy.Start: 12/02/2004Missing/incomplete/invalid rendering provider name.Start: 12/02/2004Missing/incomplete/invalid rendering provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid rending provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid service facility name.Start: 12/02/2004Missing/incomplete/invalid service facility primary identifier.Start: 12/02/2004Missing/incomplete/invalid service facility primary address.Start: 12/02/2004Missing/incomplete/invalid service facility secondary identifier.Start: 12/02/2004Missing/incomplete/invalid supervising provider name.Start: 12/02/200464

ReasonCodesN297N298N299N300N301N302N303N304N305N306N307N308N309N310DescriptionMissing/incomplete/invalid supervising provider primary identifier.Start: 12/02/2004Missing/incomplete/invalid supervising provider secondary identifier.Start: 12/02/2004Missing/incomplete/invalid occurrence date(s).Start: 12/02/2004Missing/incomplete/invalid occurrence span date(s).Start: 12/02/2004Missing/incomplete/invalid procedure date(s).Start: 12/02/2004Missing/incomplete/invalid other procedure date(s).Start: 12/02/2004Missing/incomplete/invalid principal procedure date.Start: 12/02/2004Missing/incomplete/invalid dispensed date.Start: 12/02/2004Missing/incomplete/invalid accident date.Start: 12/02/2004Missing/incomplete/invalid acute manifestation date.Start: 12/02/2004Missing/incomplete/invalid adjudication or payment date.Start: 12/02/2004Missing/incomplete/invalid appliance placement date.Start: 12/02/2004Missing/incomplete/invalid assessment date.Start: 12/02/2004Missing/incomplete/invalid assumed or relinquished care date.Start: 12/02/200465

ReasonCodesN311N312N313N314N315N316N317N318N319N320N321N322N323N324DescriptionMissing/incomplete/invalid authorized to return to work date.Start: 12/02/2004Missing/incomplete/invalid begin therapy date.Start: 12/02/2004Missing/incomplete/invalid certification revision date.Start: 12/02/2004Missing/incomplete/invalid diagnosis date.Start: 12/02/2004Missing/incomplete/invalid disability from date.Start: 12/02/2004Missing/incomplete/invalid disability to date.Start: 12/02/2004Missing/incomplete/invalid discharge hour.Start: 12/02/2004Missing/incomplete/invalid discharge or end of care date.Start: 12/02/2004Missing/incomplete/invalid hearing or vision prescription date.Start: 12/02/2004Missing/incomplete/invalid Home Health Certification Period.Start: 12/02/2004Missing/incomplete/invalid last admission period.Start: 12/02/2004Missing/incomplete/invalid last certification date.Start: 12/02/2004Missing/incomplete/invalid last contact date.Start: 12/02/2004Missing/incomplete/invalid last seen/visit date.Start: 12/02/200466

ReasonCodesN325N326N327N328N329N330N331N332N333N334N335N336N337N338DescriptionMissing/incomplete/invalid last worked date.Start: 12/02/2004Missing/incomplete/invalid last x-ray date.Start: 12/02/2004Missing/incomplete/invalid other insured birth date.Start: 12/02/2004Missing/incomplete/invalid Oxygen Saturation Test date.Start: 12/02/2004Missing/incomplete/invalid patient birth date.Start: 12/02/2004Missing/incomplete/invalid patient death date.Start: 12/02/2004Missing/incomplete/invalid physician order date.Start: 12/02/2004Missing/incomplete/invalid prior hospital discharge date.Start: 12/02/2004Missing/incomplete/invalid prior placement date.Start: 12/02/2004Missing/incomplete/invalid re-evaluation dateStart: 12/02/2004Missing/incomplete/invalid referral date.Start: 12/02/2004Missing/incomplete/invalid replacement date.Start: 12/02/2004Missing/incomplete/invalid secondary diagnosis date.Start: 12/02/2004Missing/incomplete/invalid shipped date.Start: 12/02/200467

ReasonCodesN339N340N341N342N343N344N345N346N347N348N349DescriptionMissing/incomplete/invalid similar illness or symptom date.Start: 12/02/2004Missing/incomplete/invalid subscriber birth date.Start: 12/02/2004Missing/incomplete/invalid surgery date.Start: 12/02/2004Missing/incomplete/invalid test performed date.Start: 12/02/2004Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator(TENS) trial start date.Start: 12/02/2004Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator(TENS) trial end date.Start: 12/02/2004Date range not valid with units submitted.Start: 03/30/2005Missing/incomplete/invalid oral cavity designation code.Start: 03/30/2005Your claim for a referred or purchased service cannot be paid becausepayment has already been made for this same service to anotherprovider by a payment contractor representing the payer.Start: 03/30/2005You chose that this service/supply/drug would be rendered/suppliedand billed by a different practitioner/supplier.Start: 08/01/2005The administration method and drug must be reported to adjudicate thisservice.Start: 08/01/200568

ReasonCodesN350N351N352N353N354DescriptionMissing/incomplete/invalid description of service for a Not OtherwiseClassified (NOC) code or for an Unlisted/By Report procedure.Start: 08/01/2005 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Service date outside of the approved treatment plan service dates.Start: 08/01/2005Alert: There are no scheduled payments for this service. Submit a claimfor each patient visit.Start: 08/01/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: Benefits have been estimated, when the actual services have beenrendered, additional payment will be considered based on the submittedclaim.Start: 08/01/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Incomplete/invalid invoiceStart: 08/01/200569

ReasonCodesN355DescriptionAlert: The law permits exceptions to the refund requirement in twocases: - If you did not know, and could not have reasonably beenexpected to know, that we would not pay for this service; or - If younotified the patient in writing before providing the service that youbelieved that we were likely to deny the service, and the patient signed astatement agreeing to pay for the service.If you come within either exception, or if you believe the carrier waswrong in its determination that we do not pay for this service, youshould request appeal of this determination within 30 days of the date ofthis notice. Your request for review should include any additionalinformation necessary to support your position.If you request an appeal within 30 days of receiving this notice, you maydelay refunding the amount to the patient until you receive the results ofthe review. If the review decision is favorable to you, you do not need tomake any refund. If, however, the review is unfavorable, the lawspecifies that you must make the refund within 15 days of receiving theunfavorable review decision.The law also permits you to request an appeal at any time within 120days of the date you receive this notice. However, an appeal requestthat is received more than 30 days after the date of this notice, does notpermit you to delay making the refund. Regardless of when a review isrequested, the patient will be notified that you have requested one, andwill receive a copy of the determination.The patient has received a separate notice of this denial decision. Thenotice advises that he/she may be entitled to a refund of any amountspaid, if you should have known that we would not pay and did not tellhim/her. It also instructs the patient to contact our office if he/she doesnot hear anything about a refund within 30 days70Start: 08/01/2005 | Last Modified: 04/01/2007Notes: (Modified 11/18/05, Modified 4/1/07)

ReasonCodesN356N357N358N359N360N362N363N364DescriptionThis service is not covered when performed with, or subsequent to, anon-covered service.Start: 08/01/2005Time frame requirements between this service/procedure/supply and arelated service/procedure/supply have not been met.Start: 11/18/2005Alert: This decision may be reviewed if additional documentation asdescribed in the contract or plan benefit documents is submitted.Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Missing/incomplete/invalid height.Start: 11/18/2005Alert: Coordination of benefits has not been calculated when estimatingbenefits for this pre-determination. Submit payment information fromthe primary payer with the secondary claim.Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)The number of Days or Units of Service exceeds our acceptablemaximum.Start: 11/18/2005Alert: in the near future we are implementing new policies/proceduresthat would affect this determination.Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)Alert: According to our agreement, you must waive the deductibleand/or coinsurance amounts.Start: 11/18/2005 | Last Modified: 04/01/2007Notes: (Modified 4/1/07)71

ReasonCodesN365N366N367N368N369N370N371N372N373DescriptionThis procedure code is not payable. It is for reporting/informationpurposes only.Start: 04/01/2006Requested information not provided. The claim will be reopened if theinformation previously requested is submitted within one year after thedate of this denial notice.Start: 04/01/2006Alert: The claim information has been forwarded to a ConsumerSpending Account processor for review; for example, flexible spendingaccount or health savings account.Start: 04/01/2006 | Last Modified: 07/01/2008Notes: (Modified 4/1/07, 11/5/07, 7/1/08)You must appeal the determination of the previously adjudicated claim.Start: 04/01/2006Alert: Although this claim has been processed, it is deficient accordingto state legislation/regulation.Start: 04/01/2006Billing exceeds the rental months covered/approved by the payer.Start: 08/01/2006Alert: title of this equipment must be transferred to the patient.Start: 08/01/2006Only reasonable and necessary maintenance/service charges arecovered.Start: 08/01/2006It has been determined that another payer paid the services as primarywhen they were not the primary payer. Therefore, we are refunding tothe payer that paid as primary on your behalf.Start: 12/01/200672

ReasonCodesN374N375N376N377N378N379N380N381N382N383N384DescriptionPrimary Medicare Part A insurance has been exhausted and a Part BRemittance Advice is required.Start: 12/01/2006Missing/incomplete/invalid questionnaire/information required todetermine dependent eligibility.Start: 12/01/2006Subscriber/patient is assigned to active military duty, therefore primarycoverage may be TRICARE.Start: 12/01/2006Payment based on a processed replacement claim.Start: 12/01/2006 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)Missing/incomplete/invalid prescription quantity.Start: 12/01/2006Claim level information does not match line level information.Start: 12/01/2006The original claim has been processed, submit a corrected claim.Start: 04/01/2007Consult our contractual agreement for restrictions/billing/paymentinformation related to these charges.Start: 04/01/2007Missing/incomplete/invalid patient identifier.Start: 04/01/2007Services deemed cosmetic are not coveredStart: 04/01/2007Records indicate that the referenced body part/tooth has been removedin a previous procedure.Start: 04/01/200773

ReasonCodesN385N386N387N388N389N390N391N392N393DescriptionNotification of admission was not timely according to published planprocedures.Start: 04/01/2007 | Last Modified: 11/05/2007Notes: (Modified 11/5/07)This decision was based on a National Coverage Determination (NCD).An NCD provides a coverage determination as to whether a particularitem or service is covered. A copy of this policy is available athttp://www.cms.hhs.gov/mcd/search.asp. If you do not have webaccess, you may contact the contractor to request a copy of the NCD.Start: 04/01/2007Alert: Submit this claim to the patient's other insurer for potentialpayment of supplemental benefits. We did not forward the claiminformation.Start: 04/01/2007 | Last Modified: 03/01/2009Notes: (Modified 3/1/2009)Missing/incomplete/invalid prescription numberStart: 08/01/2007Duplicate prescription number submitted.Start: 08/01/2007This service/report cannot be billed separately.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Missing emergency department records.Start: 08/01/2007Incomplete/invalid emergency department records.Start: 08/01/2007Missing progress notes/report.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)74

ReasonCodesN394N395N396N397N398N399N400N401N402N403N404N405DescriptionIncomplete/invalid progress notes/report.Start: 08/01/2007 | Last Modified: 07/01/2008Notes: (Modified 7/1/08)Missing laboratory report.Start: 08/01/2007Incomplete/invalid laboratory report.Start: 08/01/2007Benefits are not available for incomplete service(s)/undelivered item(s).Start: 08/01/2007Missing elective consent form.Start: 08/01/2007Incomplete/invalid elective consent form.Start: 08/01/2007Alert: Electronically enabled providers should submit claimselectronically.Start: 08/01/2007Missing periodontal charting.Start: 08/01/2007Incomplete/invalid periodontal charting.Start: 08/01/2007Missing facility certification.Start: 08/01/2007Incomplete/invalid facility certification.Start: 08/01/2007This service is only covered when the donor's insurer(s) do not providecoverage for the service.Start: 08/01/200775

ReasonCodesN406N407N408N409N410N418N419N420N421N422DescriptionThis service is only covered when the recipient's insurer(s) do notprovide coverage for the service.Start: 08/01/2007You are not an approved submitter for this transmission format.Start: 08/01/2007This payer does not cover deductibles assessed by a previous payer.Start: 08/01/2007This service is related to an accidental injury and is not covered unlessprovided within a specific time frame from the date of the accident.Start: 08/01/2007This is not covered unless the prescription changes.Start: 08/01/2007Misrouted claim. See the payer's claim submission instructions.Start: 08/01/2007Claim payment was the result of a payer's retroactive adjustment due toa retroactive rate change.Start: 08/01/2007Claim payment was the result of a payer's retroactive adjustment due toa Coordination of Benefits or Third Party Liability Recovery.Start: 08/01/2007Claim payment was the result of a payer's retroactive adjustment due toa review organization decision.Start: 08/01/2007 | Last Modified: 05/08/2008Notes: (Modified 2/29/08, typo fixed 5/8/08)Claim payment was the result of a payer's retroactive adjustment due toa payer's contract incentive program.Start: 08/01/2007 | Last Modified: 05/08/2008Notes: (Typo fixed 5/8/08)76

ReasonCodesN423N424N425N426N427N428N429N430N431N432N433N434DescriptionClaim payment was the result of a payer's retroactive adjustment due toa non standard program.Start: 08/01/2007Patient does not reside in the geographic area required for this type ofpayment.Start: 08/01/2007Statutorily excluded service(s).Start: 08/01/2007No coverage when self-administered.Start: 08/01/2007Payment for eyeglasses or contact lenses can be made only aftercataract surgery.Start: 08/01/2007Service/procedure not covered when performed in this place of service.Start: 08/01/2007This is not covered since it is considered routine.Start: 08/01/2007Procedure code is inconsistent with the units billed.Start: 11/05/2007Service is not covered with this procedure.Start: 11/05/2007Adjustment based on a Recovery Audit.Start: 11/05/2007Resubmit this claim using only your National Provider Identifier (NPI)Start: 02/29/2008Missing/Incomplete/Invalid Present on Admission indicator.Start: 07/01/200877

ReasonCodesN435N436N437N438N439N440N441N442N443N444N445N446DescriptionExceeds number/frequency approved /allowed within time periodwithout support documentation.Start: 07/01/2008The injury claim has not been accepted and a mandatory medicalreimbursement has been made.Start: 07/01/2008Alert: If the injury claim is accepted, these charges will be reconsidered.Start: 07/01/2008This jurisdiction only accepts paper claimsStart: 07/01/2008Missing anesthesia physical status report/indicators.Start: 07/01/2008Incomplete/invalid anesthesia physical status report/indicators.Start: 07/01/2008This missed appointment is not covered.Start: 07/01/2008Payment based on an alternate fee schedule.Start: 07/01/2008Missing/incomplete/invalid total time or begin/end time.Start: 07/01/2008Alert: This facility has not filed the Election for High Cost Outlier formwith the Division of Workers' Compensation.Start: 07/01/2008Missing document for actual cost or paid amount.Start: 07/01/2008Incomplete/invalid document for actual cost or paid amount.Start: 07/01/200878

ReasonCodesN447N448N449N450N451N452N453N454N455N456N457N458N459DescriptionPayment is based on a generic equivalent as required documentationwas not provided.Start: 07/01/2008This drug/service/supply is not included in the fee schedule orcontracted/legislated fee arrangementStart: 07/01/2008Payment based on a comparable drug/service/supply.Start: 07/01/2008Covered only when performed by the primary treating physician or thedesignee.Start: 07/01/2008Missing Admission Summary Report.Start: 07/01/2008Incomplete/invalid Admission Summary Report.Start: 07/01/2008Missing Consultation Report.Start: 07/01/2008Incomplete/invalid Consultation Report.Start: 07/01/2008Missing Physician Order.Start: 07/01/2008Incomplete/invalid Physician Order.Start: 07/01/2008Missing Diagnostic Report.Start: 07/01/2008Incomplete/invalid Diagnostic Report.Start: 07/01/2008Missing Discharge Summary.Start: 07/01/200879

ReasonCodesN460N461N462N463N464N465N466N467N468N469N470N471N472DescriptionIncomplete/invalid Discharge Summary.Start: 07/01/2008Missing Nursing Notes.Start: 07/01/2008Incomplete/invalid Nursing Notes.Start: 07/01/2008Missing support data for claim.Start: 07/01/2008Incomplete/invalid support data for claim.Start: 07/01/2008Missing Physical Therapy Notes/Report.Start: 07/01/2008Incomplete/invalid Physical Therapy Notes/Report.Start: 07/01/2008Missing Report of Tests and Analysis Report.Start: 07/01/2008Incomplete/invalid Report of Tests and Analysis Report.Start: 07/01/2008Alert: Claim/Service(s) subject to appeal process, see section 935 ofMedicare Prescription Drug, Improvement, and Modernization Act of2003 (MMA).Start: 07/01/2008This payment will complete the mandatory medical reimbursement limit.Start: 07/01/2008Missing/incomplete/invalid HIPPS Rate Code.Start: 07/01/2008Payment for this service has been issued to another provider.Start: 07/01/200880

ReasonCodesN473N474N475N476N477N478N479N480N481N482N483N484N485DescriptionMissing certification.Start: 07/01/2008Incomplete/invalid certificationStart: 07/01/2008Missing completed referral form.Start: 07/01/2008Incomplete/invalid completed referral formStart: 07/01/2008Missing Dental Models.Start: 07/01/2008Incomplete/invalid Dental ModelsStart: 07/01/2008Missing Explanation of Benefits (Coordination of Benefits or MedicareSecondary Payer).Start: 07/01/2008Incomplete/invalid Explanation of Benefits (Coordination of Benefits orMedicare Secondary Payer).Start: 07/01/2008Missing Models.Start: 07/01/2008Incomplete/invalid ModelsStart: 07/01/2008Missing Periodontal Charts.Start: 07/01/2008Incomplete/invalid Periodontal ChartsStart: 07/01/2008Missing Physical Therapy Certification.Start: 07/01/200881

ReasonCodesN486N487N488N489N490N491N492N493N494N495N496N497N498DescriptionIncomplete/invalid Physical Therapy Certification.Start: 07/01/2008Missing Prosthetics or Orthotics Certification.Start: 07/01/2008Incomplete/invalid Prosthetics or Orthotics CertificationStart: 07/01/2008Missing referral form.Start: 07/01/2008Incomplete/invalid referral formStart: 07/01/2008Missing/Incomplete/Invalid Exclusionary Rider Condition.Start: 07/01/2008Alert: A network provider may bill the member for this service if themember requested the service and agreed in writing, prior to receivingthe service, to be financially responsible for the billed charge.Start: 07/01/2008Missing Doctor First Report of Injury.Start: 07/01/2008Incomplete/invalid Doctor First Report of Injury.Start: 07/01/2008Missing Supplemental Medical Report.Start: 07/01/2008Incomplete/invalid Supplemental Medical Report.Start: 07/01/2008Missing Medical Permanent Impairment or Disability Report.Start: 07/01/2008Incomplete/invalid Medical Permanent Impairment or Disability Report.Start: 07/01/200882

ReasonCodesN499N500N501N502N503N504N505N506N507N508DescriptionMissing Medical Legal Report.Start: 07/01/2008Incomplete/invalid Medical Legal Report.Start: 07/01/2008Missing Vocational Report.Start: 07/01/2008Incomplete/invalid Vocational Report.Start: 07/01/2008Missing Work Status Report.Start: 07/01/2008Incomplete/invalid Work Status Report.Start: 07/01/2008Alert: This response includes only services that could be estimated inreal time. No estimate will be provided for the services that could not beestimated in real time.Start: 11/01/2008Alert: This is an estimate of the member's liability based on theinformation available at the time the estimate was processed. Actualcoverage and member liability amounts will be determined when theclaim is processed. This is not a pre-authorization or a guarantee ofpayment.Start: 11/01/2008Plan distance requirements have not been met.Start: 11/01/2008Alert: This real time claim adjudication response represents the memberresponsibility to the provider for services reported. The member willreceive an Explanation of Benefits electronically or in the mail. Contactthe insurer if there are any questions.Start: 11/01/200883

ReasonCodesN509N510N511N512N513N514N516N517DescriptionAlert: A current inquiry shows the member's Consumer SpendingAccount contains sufficient funds to cover the member liability for thisclaim/service. Actual payment from the Consumer Spending Accountwill depend on the availability of funds and determination of eligibleservices at the time of payment processing.Start: 11/01/2008Alert: A current inquiry shows the member's Consumer SpendingAccount does not contain sufficient funds to cover the member'sliability for this claim/service. Actual payment from the ConsumerSpending Account will depend on the availability of funds anddetermination of eligible services at the time of payment processing.Start: 11/01/2008Alert: Information on the availability of Consumer Spending Accountfunds to cover the member liability on this claim/service is not availableat this time.Start: 11/01/2008Alert: This is the initial remit of a non-NCPDP claim originally submittedreal-time without change to the adjudication.Start: 11/01/2008Alert: This is the initial remit of a non-NCPDP claim originally submittedreal-time with a change to the adjudication.Start: 11/01/2008Consult plan benefit documents/guidelines for information aboutrestrictions for this service.Start: 11/01/2008Records indicate a mismatch between the submitted NPI and EIN.Start: 03/01/2009Resubmit a new claim with the requested information.Start: 03/01/200984

ReasonCodesN518N519N520N521N522DescriptionNo separate payment for accessories when furnished for use withoxygen equipment.Start: 03/01/2009Invalid combination of HCPCS modifiers.Start: 07/01/2009Alert: Payment made from a Consumer Spending Account.Start: 07/01/2009Mismatch between the submitted provider information and the providerinformation stored in our system.Start: 11/01/2009Duplicate of a claim processed as a crossover claim.Start: 11/01/200985